Inr J. Rudiarton Oncology Bwl Phw Vol. 24, P. 991 Printed I” the U.S.A. All nghts reserved
Copyright
0360-3016/92 $5.00 + .oO 0 1992 Pergamon Press Ltd.
??Correspondence RESPONSE
TO THE RESIDENCY MATCH RADIATION ONCOLOGY
IN
Match. We will be joining the National Residency Matching Program (NRMP) which handles well over 90% of the matched positions in the United States. Over 85% of the programs endorsed this decision. We appear to be well on our way in joining the “mainstream” of American medicine as the last and final medical specialty to institute a centralized match system. I am confident that we will look back upon this as an important and successful decision.
To fhe Ediror. Dr. Lichter has presented a well-written, informative and balanced analysis of the residency match in Radiation Oncology (Volume 22: 1147-l 154). The author’s information, however, should be complemented with the recent experiences of residents currently training in radiation oncology. At the 1991 ASTRO Resident Practice Entry Seminar. sponsored by the Association of Residents in Radiation Oncology (ARRO), an informal survey of the lOO+ residents present demonstrated nearly 100% support for a centralized match in radiation oncology. A number of anecdotal stories told by current residents could explain the strong support for a residency match. Most current residents had interviewed in programs at widely variable times and were offered positions in training programs which frequently required a written commitment even prior to the candidate’s next scheduled interview at other programs. Many residents were forced to choose a training program based on irrelevant factors associated with the interviewing process, rather than with the important issues of quality and compatibility of a training program. Some residents accepted multiple positions while continuing to interview, only later to cancel all offers except at their preferred training program. (One anonymous candidate cancelled 6 “accepted” positions.) Because this practice has been anticipated by some program directors, more than one training program continued to interview even after “filling” their program. Residents and medical students who unexpectedly interviewed in “filled” programs were understandably frustrated and experienced unnecessary financial burden. These unethical and frustrating practices would be limited by the constraints of a centralized match program. The current decentralized process can magnify secretarial or clerical errors. In one horrendous exampie, one training program mailed 50 acceptance letters to candidates who actually should have received rejection letters. The required recourse of candidates who had “accepted” these positions over other program offers was significant. A computerized match program with good quality control would limit the impact and probability of such an error. In addition, the synchrony ofcomputerized match results could give unmatched candidates greater opportunities to iill open radiation oncology training positions or seek residency training elsewhere, rather than dragging out the process past the “eleventh hour.” A residency match permits candidates to objectively, sequentially, and candidly interview at several programs with expected expenses and may enhance the chance of compatibility between trainee and program. It is time that our specialty joins other fields in assuring fairness in training opportunities. A match program can influence the quality of resident applicants, especially among current medical students interested in radiation oncology but hesitant to challenge the obstacles in attaining a residency in radiation oncology. We srron& urge the Society ofchairmen of Academic Radiation Oncology Programs (SCAROP) to institute a centralized matching program for radiation oncology in the immediate future. KENNETH T. BASTIN, M.D. Chairman, Executive Board Association of Residents in Radiation I 101 Market Street, 14th Floor Philadelphia, PA I9 I07
RESPONSE
ALLEN S. LIGHTER,M.D.
Professor and Chairman Department of Radiation Oncology The University of Michigan Medical School UH-B2C490, Box 00 10 1300 E. Medical Center Drive Ann Arbor. MI 48109-0010 THE “BOTTOM
LINE”-RESPONSE
TO DR. HANKS
To t/w Editor: We appreciate the comments by Dr. Hanks with regard to our recent report. We agree that the incidence of uositive nost-irradiation prostatic biopsies will vary widely between institutions fbr several reasons, the most important of which is probably selection bias. The majority of patients in our series were biopsied following external beam radiation therapy on the basis of an abnormal digital rectal exam or elevated PSA. In addition, the biopsy technique and experience of the pathologist interpreting such biopsies may greatly impact upon the positivity rate given that a single biopsy yields only a I mm core of tissue. For the past several years, urologists at Stanford have used a methodical and comprehensive biopsy protocol using transrectal ultrasound-guidance to take samples from six pre-determined locations in the gland as well as any suspicious areas. Therefore, we cannot begin to answer the question of radiation therapy “treatment effectiveness” by these studies until the above variables (among others) are controlled as is proposed for future RTOC trials. We must continue to address the more important, “bottom line” question of the clinical sigmjkance of a positive biopsy. The overwhelming determinant of survival among these patients remains the presence or absence of distant relapse. We know that very few patients die as a result of their locally progressive disease alone. We have identified 65 patients with positive biopsies who remain free of distant relapse 2-21 years from the time of re-biopsy. Clearly a “positive” biopsy was not significant for many of these patients. It appears that a simple digital rectal exam may be as useful as any other means at our disposal in determining those patients at greatest risk for distant relapse (I). Unfortunately identifying those patients for whom a positive biopsy may be significant is only half the battle. Both the optimal type as well as timing of intervention must then be considered. We need better methods of determining the presence of clinically occult metastases. Perhaps recent refinements in MRI imaging and laparoscopic pelvic lymph node sampling will help us to better separate patients who would benefit from local “salvage” intervention from those for whom the horse is already out of the barn and up the road. BRADLEY R. PRESTIDGE,M.D.
Department of Radiation Oncology Wilford Hall USAF Medical Center San Antonio, TX 78250
Oncology
IRVING KAPLAN, M.D. Joint Center for Radiation 50 Binnev Street Boston. MA 02 I I5
TO DR. BASTIN
To the Editor: Dr. Bastin presents several additional compelling reasons for the institution of the centralized match for radiation oncology training positions. While it is acknowledged that no candidate matching process is “perfect,” there appears to be an overwhelming consensus that a centralized system will represent a major improvement over the ad hoc arrangement that has previously existed. In a field like radiation oncology where there are at least 1.5 applicants for every open position, each program will fill their positions with highly qualified candidates. I am pleased to report that at the April 1992 meeting of the Society of Chairmen of Academic Radiation Oncology Programs (SCAROP), an overwhelming endorsement was given to reinstitute a centralized
Therapy
RICHARD S. Cox, Ph.D. MALCOLM A. BAGSHAW, M.D.
Department of Radiation Oncology Stanford University School of Medicine Stanford, CA 94305 I. Prestidge, B. R., Kaplan, I., Cox, R. S., Bagshaw, M. A. Predictors of survival after a positive post-irradiation prostate biopsy. To be presented at ASTRO meeting 1992. 991
Copyright
0360-3016/92 $5.00 + .oO 0 1992 Pergamon Press Ltd.
??Correspondence RESPONSE
TO THE RESIDENCY MATCH RADIATION ONCOLOGY
IN
Match. We will be joining the National Residency Matching Program (NRMP) which handles well over 90% of the matched positions in the United States. Over 85% of the programs endorsed this decision. We appear to be well on our way in joining the “mainstream” of American medicine as the last and final medical specialty to institute a centralized match system. I am confident that we will look back upon this as an important and successful decision.
To fhe Ediror. Dr. Lichter has presented a well-written, informative and balanced analysis of the residency match in Radiation Oncology (Volume 22: 1147-l 154). The author’s information, however, should be complemented with the recent experiences of residents currently training in radiation oncology. At the 1991 ASTRO Resident Practice Entry Seminar. sponsored by the Association of Residents in Radiation Oncology (ARRO), an informal survey of the lOO+ residents present demonstrated nearly 100% support for a centralized match in radiation oncology. A number of anecdotal stories told by current residents could explain the strong support for a residency match. Most current residents had interviewed in programs at widely variable times and were offered positions in training programs which frequently required a written commitment even prior to the candidate’s next scheduled interview at other programs. Many residents were forced to choose a training program based on irrelevant factors associated with the interviewing process, rather than with the important issues of quality and compatibility of a training program. Some residents accepted multiple positions while continuing to interview, only later to cancel all offers except at their preferred training program. (One anonymous candidate cancelled 6 “accepted” positions.) Because this practice has been anticipated by some program directors, more than one training program continued to interview even after “filling” their program. Residents and medical students who unexpectedly interviewed in “filled” programs were understandably frustrated and experienced unnecessary financial burden. These unethical and frustrating practices would be limited by the constraints of a centralized match program. The current decentralized process can magnify secretarial or clerical errors. In one horrendous exampie, one training program mailed 50 acceptance letters to candidates who actually should have received rejection letters. The required recourse of candidates who had “accepted” these positions over other program offers was significant. A computerized match program with good quality control would limit the impact and probability of such an error. In addition, the synchrony ofcomputerized match results could give unmatched candidates greater opportunities to iill open radiation oncology training positions or seek residency training elsewhere, rather than dragging out the process past the “eleventh hour.” A residency match permits candidates to objectively, sequentially, and candidly interview at several programs with expected expenses and may enhance the chance of compatibility between trainee and program. It is time that our specialty joins other fields in assuring fairness in training opportunities. A match program can influence the quality of resident applicants, especially among current medical students interested in radiation oncology but hesitant to challenge the obstacles in attaining a residency in radiation oncology. We srron& urge the Society ofchairmen of Academic Radiation Oncology Programs (SCAROP) to institute a centralized matching program for radiation oncology in the immediate future. KENNETH T. BASTIN, M.D. Chairman, Executive Board Association of Residents in Radiation I 101 Market Street, 14th Floor Philadelphia, PA I9 I07
RESPONSE
ALLEN S. LIGHTER,M.D.
Professor and Chairman Department of Radiation Oncology The University of Michigan Medical School UH-B2C490, Box 00 10 1300 E. Medical Center Drive Ann Arbor. MI 48109-0010 THE “BOTTOM
LINE”-RESPONSE
TO DR. HANKS
To t/w Editor: We appreciate the comments by Dr. Hanks with regard to our recent report. We agree that the incidence of uositive nost-irradiation prostatic biopsies will vary widely between institutions fbr several reasons, the most important of which is probably selection bias. The majority of patients in our series were biopsied following external beam radiation therapy on the basis of an abnormal digital rectal exam or elevated PSA. In addition, the biopsy technique and experience of the pathologist interpreting such biopsies may greatly impact upon the positivity rate given that a single biopsy yields only a I mm core of tissue. For the past several years, urologists at Stanford have used a methodical and comprehensive biopsy protocol using transrectal ultrasound-guidance to take samples from six pre-determined locations in the gland as well as any suspicious areas. Therefore, we cannot begin to answer the question of radiation therapy “treatment effectiveness” by these studies until the above variables (among others) are controlled as is proposed for future RTOC trials. We must continue to address the more important, “bottom line” question of the clinical sigmjkance of a positive biopsy. The overwhelming determinant of survival among these patients remains the presence or absence of distant relapse. We know that very few patients die as a result of their locally progressive disease alone. We have identified 65 patients with positive biopsies who remain free of distant relapse 2-21 years from the time of re-biopsy. Clearly a “positive” biopsy was not significant for many of these patients. It appears that a simple digital rectal exam may be as useful as any other means at our disposal in determining those patients at greatest risk for distant relapse (I). Unfortunately identifying those patients for whom a positive biopsy may be significant is only half the battle. Both the optimal type as well as timing of intervention must then be considered. We need better methods of determining the presence of clinically occult metastases. Perhaps recent refinements in MRI imaging and laparoscopic pelvic lymph node sampling will help us to better separate patients who would benefit from local “salvage” intervention from those for whom the horse is already out of the barn and up the road. BRADLEY R. PRESTIDGE,M.D.
Department of Radiation Oncology Wilford Hall USAF Medical Center San Antonio, TX 78250
Oncology
IRVING KAPLAN, M.D. Joint Center for Radiation 50 Binnev Street Boston. MA 02 I I5
TO DR. BASTIN
To the Editor: Dr. Bastin presents several additional compelling reasons for the institution of the centralized match for radiation oncology training positions. While it is acknowledged that no candidate matching process is “perfect,” there appears to be an overwhelming consensus that a centralized system will represent a major improvement over the ad hoc arrangement that has previously existed. In a field like radiation oncology where there are at least 1.5 applicants for every open position, each program will fill their positions with highly qualified candidates. I am pleased to report that at the April 1992 meeting of the Society of Chairmen of Academic Radiation Oncology Programs (SCAROP), an overwhelming endorsement was given to reinstitute a centralized
Therapy
RICHARD S. Cox, Ph.D. MALCOLM A. BAGSHAW, M.D.
Department of Radiation Oncology Stanford University School of Medicine Stanford, CA 94305 I. Prestidge, B. R., Kaplan, I., Cox, R. S., Bagshaw, M. A. Predictors of survival after a positive post-irradiation prostate biopsy. To be presented at ASTRO meeting 1992. 991
